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Jaycee Academy of Smart Initiatives for Empowerment
JASMINE APPLICATION
Send to: JCI INDIA, National Headquarter, 2nd floor, Ami-kalash, Ami Complex, IC Colony Road, Borivali(W)
Mumbai-400 103, Ph: 022-28913355, 28912354. E-mail: prgns@jciindia.in
Name of the Applicant
Standard
Sex
Date of Birth
Female
Male
Name of the Sponsoring LOM
Zone
Area
Application for
South
North
Postal Address of
applicant
City
Phone (Bus) with STD code
Pin
Phone (Res)
E-Mail :*
State
Mobile*
Mobile
Web Site :
Which profession you wish to
take as future career & why:
Name of the School/Institution
You are presently studying
Other Information
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When did you attend Local level Leadership 21st
Century program / Empowering Youth
What are your hobbies
What is your understanding by Junior Chamber?
What is your expectation in this program (Brief in
two lines)
Have you attended JASMINE before, when?
Please send this application along with DD of Rs. 1500/- in favor of “JCI INDIA”, payable at
MUMBAI to JCI India National Head quarter address. Application along with DD must reach at
NHQ within 10.04.2015.
Declaration to be signed by the Applicant
I here by declare that my ward/child is attending the above program of JCI India by our willingness to participate. He/She does not
suffer from any ailment or communicable disease. We will not hold JCI India or its representatives solely or individually responsible
for any sort of injury or ailment that may cause during and after the camp. We understand that this camp is organized in good
interest of the overall development of the youth.
Signature of Parent/Guardian
Signature of the Zone President
Date
Signature of the applicant
Signature of sponsoring LOM president